THE HEALTH BURDEN, SCIENCE, SURVEILLANCE, POLICY DEVELOPMENTS AND AREAS OF FUTURE ACTION - AN OVERVIEW OF ANTIMICROBIAL RESISTANCE
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AN OVERVIEW OF ANTIMICROBIAL RESISTANCE
THE HEALTH BURDEN, SCIENCE, SURVEILLANCE,
POLICY DEVELOPMENTS AND
AREAS OF FUTURE ACTION
MAY 2022
About EPHA EPHA is a change agent – Europe’s leading NGO alliance advocating for better health. We are a dynamic member-led organisation, made up of public health civil society, patient groups, health professionals, and disease groups working together to improve health and strengthen the voice of public health in Europe. EPHA's work on Antimicrobial Resistance EPHA's work on Global Public Health focuses on the leading health concerns: antimicrobial resistance (AMR) threatens human, animal and environmental health and, if left unchecked, poses an unprecedented risk to health systems and the economy. Our work therefore strives to ensure AMR remains high on the political agenda, under a One Health approach. By Kirsty Douglas • Policy Assistant for Global Public Health The European Public Health Alliance has received funding under an operating grant from the European Union’s EU4Health Programme (2021-2027). The content of this document represents the views of the authors only and is their sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the European Health and Digital Executive Agency (HaDEA) or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains. Transparency Register Number: 18941013532-08
CONTENTS Introduction: The Global Health Burden 4 Microbes, Antimicrobials and AMR 5 Surveillance and Monitoring 7 Policy Developments 8 Areas for Future Action 10
4| EPHA | AN OVERVIEW OF AMR
Introduction: The Global Health Burden
Antimicrobial resistance (AMR) is a global public health concern, with the World Health Organization
designating it a leading health threat.1 The 2022 GRAM Global Burden Report,2 calculated bacterial
AMR to be associated with 4.95 million deaths in 2019, including 1.27 million attributable deaths,
placing AMR as a leading cause of mortality globally. This data updates the 2016 Jim O’Neil Report,3
which then estimated the yearly AMR attributable deaths to be 700 000. The Global Burden Report
also presented regional AMR mortality, as well as the leading pathogens associated with resistance.
Within the European Union (EU)/European Economic Area (EEA), a study using data from 2015, showed
bacterial AMR to be responsible for 33 000 deaths that year.4
The consequences are already being felt by health services, as patients with antimicrobial resistant
infections are often hospitalised for longer, require more expensive medicine courses, and are more
likely to have worse health outcomes, with some infections untreatable. Vulnerable groups, such as pre-
term infants and the immunocompromised, have an additional risk due to their increased susceptibility
to infections generally.5 AMR also threatens outcomes of surgical, medical, and dental treatments,
putting patients at increased danger of serious complications, including disability and death, if they
acquire antimicrobial-resistant infections during the treatment process.6
Compounding the situation are issues including a lack of new antimicrobial medicines being developed,
due to a lack of viable market; problems of access – financially and practically; and quality of existing
antimicrobials.7 However, the direct replacement of antimicrobials only offers a short-term solution.
The establishment of long-term preventative measures, under an inter-sectoral One Health approach –
considering human, animal, plant, and environmental aspects – is essential to ending the crisis.
The following overview is designed to set the scene on AMR in a concise and accessible manner for
those working across health, research, and policy, as well as the public, who are seeking to broaden
their knowledge on this health threat and engage in dialogue and collaboration. It presents a scientific
summary on antimicrobial resistance, current surveillance efforts, recent policy developments and
areas of future action, with a focus on the global and EU level.
1 WHO. (2021). Factsheet: Antimicrobial Resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
2 Antimicrobial Resistance Collaborators. (2022). Global Burden of Bacterial Antimicrobial Resistance in 2019: a systematic analysis. The Lancet,
399(10325), 629-655. https://doi.org/10.1016/S0140-6736(21)02724-0
3 The Jim O’Neil Report acknowledged that their figure may be a low estimate given the scarcity of data then available, therefore these two statistics
cannot be directly compared.
O’Neil, Jim. (2016). Tackling Drug-Resistant Infections Globally. Review on Antimicrobial Resistance.
https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf
4 Cassini, Alessandro et al. (2018). Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the
EU and the European Economic Area in 2015: a population-level modelling analysis. The Lancet - Infections Diseases 19(1), 565-66.
https://doi.org/10.1016/S1473-3099(18)30605-4
5 Prestinaci, Francesca et al. (2015). Antimicrobial resistance: a global multifaceted phenomenon. Pathogens and Global Health 109(7), 309-218.
https://dx.doi.org/10.1179%2F2047773215Y.0000000030
6 WHO. (2021). Factsheets: Antimicrobial Resistance.
7 WHO. (2021). Factsheets: Antimicrobial Resistance ;
React Group. (n.d.) Problems related to quality of antibiotics. Retrieved 23 May. https://www.reactgroup.org/toolbox/understand/how-did-we-
end-up-here/problems-related-to-quality-of-antibiotics/#zp-ID-18392-280251-GJ93ZUWC
AN OVERVIEW OF AMR | EPHA |5
Microbes, Antimicrobials and AMR
Awareness of the scientific basis of AMR is key to understanding the issue, identifying surveillance
targets, and developing evidence-based policy interventions. A summary of the topic is given below.
Microbes
Microorganisms, commonly referred to as microbes, are a collective term for bacteria, viruses, fungi,
and protozoa. They can be found in water, soil, and air, as well as humans, animals, and plants – either
in a commensal (non-disease causing) or pathogenic (infection causing) relationship.8
Antimicrobials
Antimicrobials kill or prevent the growth of microbes, and are used to treat infections in humans,
animals, and plants.9 Each type of antimicrobial affects a particular anatomical characteristic or
physiological process specific to its target microbe. Antimicrobials can either be broad – targeting a
commonly shared trait within a group of microbes, or narrow – affecting a trait only present in a (few)
species, within a group. Antimicrobials effective against one species/group are therefore ineffective
when used against another species/group that do not share the targeted trait.10
Antimicrobial Resistance (AMR)
AMR is a naturally occurring process, which arises when a pathogenic microbe – pathogen – has
a genetic mutation that significantly alters an aspect of its anatomy or physiology, allowing it
to evade or resist the action of an antimicrobial medicine.11 For example, antibiotic resistance,
also called bacterial AMR, occurs when bacteria become resistant to antibiotic medicine.12
The resistant strain therefore survives exposure to the antibiotic, where other strains without this
mutation do not. The genetic advantage can then be passed on when the resistant microbe replicates
and divides itself or, in some instances, between species through horizontal gene transfer.13 An infected
individual or host – human, animal, or plant – can spread their anti-microbial resistant strain to others,
via direct or indirect transmission, e.g. between animals and humans by direct contact, via food products
or the environment.14 In time, the resistant strain becomes the most prevalent in the species, rendering
the antimicrobial medicine widely ineffective. Multidrug resistance (MDR) arises when a microbe is
resistant to multiple antimicrobial medicines that are normally effective against it.15
8 National Institute of Allergy and Infectious Diseases. 2016. Understanding Microbes in Sickness and in Health.
https://scholarworks.iupui.edu/bitstream/handle/1805/747/Understanding%20microbes%2c%20in%20sickness%20and%20in%20health.pdf
9 Purssell, E. (2019). Antimicrobials. Understanding Pharmacology in Nursing Practice 147–165.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120529/
10 Leekha, Surbhi et al. (2011). General Principles of Antimicrobial Therapy. Mayo Clin Proc 86(2), 156-167
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/pdf/mayoclinproc_86_2_013.pdf
11 WHO. (2021). Factsheets: Antimicrobial Resistance.
12 Antibiotic resistance is of particular concern, as many human infections are caused by bacteria, and many medical interventions carry a risk of
infection, such as surgery and chemotherapy.
13 Purssell, E. (2019). Antimicrobials.
14 Microbiology Society. Routes of transmission.
https://microbiologysociety.org/why-microbiology-matters/what-is-microbiology/microbes-and-the-human-body/routes-of-transmission.html
Morel C. (2019). Transmission of antimicrobial resistance from livestock agriculture to humans and from humans to animals. OECD Food, Agriculture
and Fisheries Papers, No. 133. http://dx.doi.org/10.1787/fcf77850-en
15 MDR is also commonly discussed in reference to bacteria.
ECDC. (n.d.). Factsheet for Experts: AMR. Retrieved 05 May 2022.
https://www.ecdc.europa.eu/en/antimicrobial-resistance/facts/factsheets/experts
6| EPHA | AN OVERVIEW OF AMR
Example: Mycobacterium tuberculosis is a
species of bacteria that is spread between
humans through the air and causes the disease
Tuberculosis (TB), which had 10 million cases
and 1.5 million related deaths in 2020.16
There are antibiotics that can normally target
M. tuberculosis and cure an infection, however
drug-resistant strains have developed and
spread, limiting treatment options and
accounting for half a million infections
annually.17
16 WHO. (2021). Factsheet: Tuberculosis.
https://www.who.int/news-room/fact-sheets/detail/tuber-
culosis
17 WHO. (n.d.). Tackling the Drug-resistant TB Crisis. Retrieved 19
May 2022. https://www.who.int/activities/tackling-the-drug-
resistant-tb-crisis/only-1-in-3-people-with-drug-resistant-tb-
access-care
Drivers of AMR
Whilst AMR is a naturally occurring process, certain
human activities can hasten its occurrence.18 Key
drivers occur across the One Health interface
including inappropriate, unregulated and overuse
of antimicrobials; inadequate infection prevention
and control measures; poor farming husbandry, food
processing, and distribution practices; inadequate
sewage and waste management, including in the
production and disposal of antimicrobials.
18 The Fleming Fund. (2017). What You Need to Know about Antimicrobial
Resistance (AMR). https://1doxu11lv4am2alxz12f0p5j-wpengine.
netdna-ssl.com/wp-content/uploads/LP1_AMR_A4Screen_
FinalSignOff_Jan2017.pdfAN OVERVIEW OF AMR | EPHA |7
Surveillance and Monitoring
Up-to-date data on the AMR burden is necessary for evidence-based policy decision-making to target
the areas of priority, considering the risk posed to public health and limited resources available –
financial budget, capacity etc. Below lists periodic global and European AMR surveillance reports.
Access to Medicines Foundation (AMF)
• Antimicrobial Resistance Benchmark annual report evaluates antimicrobial producing
pharmaceutical companies for their AMR limiting initiatives, including antimicrobial research
and development, manufacturing, access, and stewardship.19
European Centre of Disease Prevention and Control (ECDC)
• Annual Epidemiological Report provides data on human antimicrobial consumption in the EU/
EEA.20
• European Antimicrobial Resistance Surveillance Network (EARS-Net) annual report collects
data on invasive microbes resistant to antimicrobials in humans.21
European Food Safety Authority (EFSA) joint with ECDC, and EMA
• Antimicrobial Consumption and Resistance in Bacteria in Human and Animals (JIACRA) report
series, monitors antimicrobials in humans and food producing animals the EU/EEA.22
European Medicines Agency (EMA)
• European Surveillance of Veterinary Antimicrobial Consumption (ESVAC) annual report for sales
of veterinary antimicrobials in European countries.23
World Health Organization (WHO)
• Antimicrobial Resistance Surveillance in Europe report series in collaboration with ECDC,
provides data on the WHO European region, including EARS-Net countries.24
• Central Asian and European Surveillance of Antimicrobial Resistance (CAESAR) annual report
provides information on coordination and surveillance of AMR in clinical settings and includes
countries in the WHO European Region that are not covered by EARS-Net.25
• Global Database for the Tripartite AMR Country Self-assessment Survey (TrACSS), produced
by the WHO, Food and Agriculture Organization of the United Nations (FAO) and OIE, is used to
track nation level progress in addressing AMR, with results made available annually.26
World Organisation for Animal Health (OIE)
• Annual Report on Antimicrobial Agents Intended for Use in Animals offers global and regional
analysis of food-producing animals.27
19 https://accesstomedicinefoundation.org/amr-benchmark
20 https://www.ecdc.europa.eu/en/surgical-site-infections/surveillance-and-disease-data/all-annual-epidemiological-reports
21 https://www.ecdc.europa.eu/en/antimicrobial-resistance/surveillance-and-disease-data/report
22 https://op.europa.eu/en/publication-detail/-/publication/5b831304-0ace-11ec-adb1-01aa75ed71a1
23 https://www.ema.europa.eu/en/veterinary-regulatory/overview/antimicrobial-resistance/european-surveillance-veterinary-antimicrobial-con-
sumption-esvac
24 https://www.ecdc.europa.eu/en/publications-data/antimicrobial-resistance-surveillance-europe-2022-2020-data
25 https://www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resistance/surveillance/central-asian-and-european-surveil-
lance-of-antimicrobial-resistance-caesar
26 https://www.who.int/publications/m/item/tripartite-amr-country-self-assessment-survey-(tracss)-2020-2021
27 https://www.oie.int/en/what-we-do/global-initiatives/antimicrobial-resistance/#ui-id-38| EPHA | AN OVERVIEW OF AMR
Policy Developments
The risk of AMR to public health has seen responses at all levels of society. This section will focus on
global and European (EU) level policy developments, outlining key stakeholders and publications.
Global Developments
In 2015, World Health Assembly (WHA) adopted the Global Action Plan on AMR28 to address antimicrobial
misuse and overuse in human medicine and food production and the risk of a post-antibiotic era. The
five objectives are to improve awareness, evidence-base, reduce incidence, optimise antimicrobial use,
and develop sustainable medical interventions.
A formal Tripartite partnership between the WHO, FAO, and OIE was made in 2018, to address AMR in
a coordinated One Health approach, and published their Monitoring and Evaluation Report29 of the
Global Action Plan the following year. The Tripartite became a Quadripartite in 2022, with the inclusion
of the United Nations Environment Programme (UNEP), with a collective goal to “preserve antimicrobial
efficacy and ensure sustainable and equitable access to antimicrobials for responsible and prudent
use in human, animal and plant health.”30 In the same year, the UNEP published the Environmental
Dimensions of AMR Report,31 with a focus on pollutants and a call to strengthen environmental action.
An ad hoc interagency coordination group (IACG) on AMR, comprised of representatives from the then
Tripartite partnership, produced the No Time To Wait Report32 in 2019. At the request of UN member
states, this document made a list of recommendations to respond to the global threat of AMR. One
recommendation realised is the formation of the Global Leaders Group on AMR (GLG). This group brings
together heads of state, current or former ministers and governmental officials, and intersectoral –
foundations, civil society and private – experts in an advisory and advocacy role, working to promote
political action on AMR.33 GLG’s AMR Priorities34 include sustained political action, transformation
in all One Health areas, improved surveillance and monitoring, increased mobilisation of financial
resources, increased medical innovation, and a better understanding of the role of the environment in
transmission, and supports the mandates of the now Quadripartite.
Internationally, in 2021, G7 finance ministers agreed on Actions to Support Antibiotic Development.35
This saw a political commitment to prioritise their own national AMR Action Plans as well as help
strengthen antibiotic research and development, to bring new drugs to market.
28 WHO. (2015). Global Action Plan on AMR. https://www.who.int/publications/i/item/9789241509763
29 FAO, OIE, WHO. (2019). Monitoring and Evaluation of the Global Action Plan on Antimicrobial Resistance.
https://www.who.int/publications/i/item/monitoring-and-evaluation-of-the-global-action-plan-on-antimicrobial-resistance
30 FAO. (2022). Antimicrobial Resistance: Quadripartite – Who We Are.
https://www.fao.org/antimicrobial-resistance/quadripartite/who-we-are/en/
31 UNEP. (2022). Environmental Dimensions of AMR: Summary for Policy Makers.
https://wedocs.unep.org/bitstream/handle/20.500.11822/38373/antimicrobial_R.pdf
32 IACG. (2019). No Time To Wait: Securing The Future From Drug-Resistant Infections. https://www.who.int/docs/default-source/documents/no-
time-to-wait-securing-the-future-from-drug-resistant-infections-en.pdf?sfvrsn=5b424d7_6
33 GLG on AMR. (2022). About us. https://www.amrleaders.org/about-us
34 GLG on AMR. (2021). Priorities of the Global Leaders Group on AMR.
https://www.amrleaders.org/resources/m/item/priorities-of-the-amr-glg-Jan-2022
35 G7. (2021). Actions to Support Antibiotic Development.
https://www.gov.uk/government/publications/g7-finance-ministers-statement-on-actions-to-support-antibiotic-developmentAN OVERVIEW OF AMR | EPHA |9
European (EU) Developments
The European Commission (EC) adopted the One Health Action Plan against AMR36 in 2017, building
upon the 2011 Action Plan37 and 2016 Council Conclusions on the Next Steps under a One Health
Approach.38 Bi-yearly Progress Reports39 have since followed. The objectives were to make the EU a
best practice region, including assisting Member States in the development of National Action Plans
(NAPs), as agreed upon in the 2015 WHA; improve research, development, and innovation; and shape
the global agenda. Political decisions that directly affect human health are predominantly the remit of
Member States, therefore NAPs are essential to ensure AMR measures in this area.
EU policy developments on AMR have included the 2019 Strategic Approach to Pharmaceuticals in
the Environment40 to address the potential impact of pharmaceuticals at all stages of their lifecycle on
the environment.41 The 2020 Pharmaceutical Strategy42 indicates plans for AMR policy development
around procurement of antimicrobials and their alternatives. In the same year, an Implementing
Decision on Monitoring and Yearly Reporting of AMR43 in zoonotic (transferrable between animals
and humans) and commensal bacteria was mandated for Member States. The adoption of the 2020
Farm to Fork Strategy44 had as its objective to reduce antimicrobial sales by 50% in animal farming
and aquaculture by 2030. This was supported by two regulations on Veterinary Medicinal Products45
and Medicated Feed46 that came into force in 2022, which included data collection on antibiotic use
in animal agriculture in Member States and foresees a list of antibiotics to be reserved for human
use only. These two regulations also have implications for third countries, where animal-derived food
products are being imported into the EU, including the banning of antibiotics being used as growth
promoters and compliance with the list of reserved antibiotics.
During the 2022 One Health Ministerial Conference on AMR, the presidency trio of France, the Czech
Republic and Sweden published a Declaration on AMR,47 indicating it as a continuing priority for their
respective presidencies of the European Council, until June 2023. Participants at this event also included
the ECDC, EFSA, WHO, FAO, OIE, and heads of EU Member State NAPs.
36 EC. (2017). A European One Health Action Plan against Antimicrobial Resistance (AMR).
https://ec.europa.eu/health/system/files/2020-01/amr_2017_action-plan_0.pdf
37 EC. (2011). COM (2011)748 - Action plan against the rising threats from Antimicrobial Resistance.
https://www.eumonitor.eu/9353000/1/j9vvik7m1c3gyxp/viuitlfp8oyd
38 EC. (2016). Council conclusions on the next steps under a One Health approach to combat antimicrobial resistance.
https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:52016XG0723(02)&from=EN
39 EC. (2022). Progress Report 2017 EU AMR Action Plan. Retrieved 27 April 2022.
https://ec.europa.eu/health/system/files/2022-04/amr_2018-2022_actionplan_progressreport_en.pdf
40 EC. (2019). European Union Strategic Approach to Pharmaceuticals in the Environment.
https://ec.europa.eu/environment/water/water-dangersub/pdf/strategic_approach_pharmaceuticals_env.PDF
41 More information about EU policy developments can be found here: EC (n.d.). EU Action on AMR. Retrieved 29 April 2022.
https://ec.europa.eu/health/antimicrobial-resistance/eu-action-antimicrobial-resistance_en
42 EC. (2020). Pharmaceutical Strategy for Europe. https://ec.europa.eu/health/system/files/2021-02/pharma-strategy_report_en_0.pdf
43 EC. (2022). Commission Implementing Decision 2020/1729. Official Journal of the European Union.
http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2020.387.01.0008.01.ENG
44 EC. (n.d.). Farm to Fork Strategy. Retrieved 27 April 2022. https://ec.europa.eu/food/horizontal-topics/farm-fork-strategy_en
45 EC. (2019). Regulation 2019/6. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32019R0006
46 EC. (2019). Regulation 2019/4. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32019R0004
47 French Presidency of the Council of the European Union. (2022). One Health Ministerial Conference on Antimicrobial Resistance.
https://presidence-francaise.consilium.europa.eu/en/news/one-health-ministerial-conference-on-antimicrobial-resistance-press-release/10 | EPHA | AN OVERVIEW OF AMR
Areas for Future Action
The current burden of AMR and future implications on global public health, if not properly and timely
addressed, are well established in literature. Surveillance and policy developments are underway, but
there still remain gaps requiring attention, as well as emerging concerns that need to be considered to
ensure AMR is addressed holistically. Below highlights areas for future action.
Surveillance Opportunities
One Health surveillance is necessary to prevent AMR build up in one area, which can in turn transmit
to others.48 AMR surveillance systems and reporting for human and animal antimicrobial consumption
are now established, though there are national and regional variances in implementation. However,
surveillance of antimicrobial use in crops and AMR environmental monitoring are not yet at the same
level.49 FAO’s plans for an AMR Monitoring (InFARM) System50 that presents global data on AMR in
food and agriculture, including antimicrobial use in crop production, is a promising development.
Environmentally, expansion of AMF’s antimicrobial production surveillance initiative and the
development of standardised and systematic antimicrobial sewage and waste disposal surveillance at
antimicrobial production plants, as well as at clinical, agri- and aquacultural sites would also assist in
understanding the full scope and spread of AMR.51
Regional surveillance is required, especially targeting areas where AMR burden is greatest. The Fleming
Fund, a UK aid programme, is supporting AMR surveillance capacity building throughout Africa and
Asia, utilising WHO’s Global Antimicrobial Resistance Surveillance System52 (GLASS). However, more
international support and partnerships would ensure that such projects achieve their implementation,
reach, output, and sustainability.
48 European Public Health Alliance (EPHA). (2019). Indicators for the Surveillance of AMR and Antimicrobial Consumption.
https://epha.org/wp-content/uploads/2018/08/AMR-indicators-briefing.pdf
49 OECD. (2019). Pharmaceutical Residues in Freshwater: Hazards and Policy Responses.
https://www.oecd.org/environment/resources/pharmaceutical-residues-in-freshwater-policy-highlights.pdf
UNEP. (2022). Environmental Dimensions of Antimicrobial Resistance: Summary for Policymakers.
https://wedocs.unep.org/bitstream/handle/20.500.11822/38373/antimicrobial_R.pdf
50 FAO. (n.d.). The International FAO Antimicrobial Resistance Monitoring (InFARM) System. Retrieved 18 May 2022.
https://www.fao.org/antimicrobial-resistance/resources/database/infarm/en/
51 AMR Stakeholder Network. (2019). Roadmap for Action on Antimicrobial Resistance.
https://epha.org/wp-content/uploads/2022/01/amr-roadmap-22.pdf
52 The Fleming Fund. (2019). Technology-supported Capacity Building on AMR Surveillance.
https://www.flemingfund.org/publications/technology-supported-capacity-building-on-amr-surveillance-findings-from-the-pilot-phase/
WHO. (n.d.). Global Antimicrobial Resistance and Use Surveillance System (GLASS). Retrieved 19 May 2022
https://www.who.int/initiatives/glassAN OVERVIEW OF AMR | EPHA | 11
Policy Opportunities
Addressing AMR drivers in a One Health approach: the 2021 G7 summit highlighted policy areas
requiring development in human health, including education, infection control, appropriate antibiotic
use and developing common indicators.53 Recent EU agricultural policy developments revolve around
preventing inappropriate antimicrobial use, yet concerns have been raised regarding their effectiveness,
given the widespread presence of high intensive livestock farming systems that sees excessive use of
antibiotics.54 That said, the EC has committed to revising current animal welfare legislation by the end of
2023, regarding the keeping, transport and slaughter of agricultural animals.55 In light of the apparent
lack of environmental surveillance initiatives and data currently available, policy developments for
sewage and waste management throughout the antimicrobials life-cycle, from production to its use in
human, animal and crops, also appears awaiting development.56
Emerging global public health issues: the COVID-19 pandemic has stimulated political attention regarding
the need for robust frameworks to effectively respond, coordinate and manage global public health
crises, as well as prevent future occurrences. These policy developments have seen initial discussions
to involve AMR, including the development of a WHO-led international pandemic prevention,
preparedness and response initiative,57 with the Global Leaders Group on AMR already signalling the
need for AMR to be explicitly considered.58 At the EU level, the creation of the Health Emergency
Response Authority (HERA)59 to respond to future health crises, has seen preparatory activity including
tendering an AMR medical countermeasures study.60 Additionally, initial effects of COVID-19 on AMR
drivers have already been observed, therefore, any wider pandemic countermeasures have the potential
to co-benefit AMR. 61
Research, development, and production of medical interventions is essential to protect population
health, thereby providing an additional line of defence. These areas sees increasing policy interest, with
new incentive models being proposed and trailed to stimulate pharmaceutical company engagement.
Attention to other medical products, such as vaccinations, or rapid diagnostic tests is also necessary,
given their potential to prevent antimicrobial use, or, for the latter, allow for selection of the most
appropriate antimicrobial and length of treatment.62
53 French Presidency of the Council of the European Union. (2022). OHMC on AMR.
54 Nunan, Coilin. For EPHA. (2022). Ending Routine Farm Antibiotic Use in Europe: Achieving responsible farm antibiotic use through improving
animal health and welfare in pig and poultry production.
https://epha.org/ending-routine-farm-antibiotic-use/
55 EC. (n.d.). Revision of the animal welfare legislation. Retrieved 18 May 2022.
https://ec.europa.eu/food/animals/animal-welfare/evaluations-and-impact-assessment/revision-animal-welfare-legislation_en
56 EPHA. (2020). Stepping up the Fight Against AMR.
https://epha.org/wp-content/uploads/2020/12/epha-amr-position-paper-updated-2020.pdf
57 WHO. (n.d.). Intergovernmental Negotiating Body. Retrieved 19 May 2022.
https://inb.who.int/
58 GLG on AMR. (2022). Why AMR Must Be a Substantive Element of the International Instrument on Pandemic Prevention, Preparedness and Re-
sponse. https://www.amrleaders.org/resources/m/item/why-amr-must-be-a-substantive-element-of-the-international-instrument-on-pan-
demic-prevention-preparedness-and-response
59 EC. (n.d.). DG HERA: Health Emergency Preparedness and Response Authority. Retrieved 19 May 2022.
https://ec.europa.eu/info/departments/health-emergency-preparedness-and-response-authority_en
60 European Health and Digital Executive Agency. (2021). A Study on bringing AMR Medical Countermeasures to the Market.
https://hadea.ec.europa.eu/calls-tenders/study-bringing-amr-medical-countermeasures-market_en ;
EPHA et al. (2021). Position Paper on the Pharmaceutical Strategy for Europe.
https://epha.org/wp-content/uploads/2021/12/position-paper-on-pharma-strategy-20.pdf
61 EPHA. (2021). The Interplay Between Antimicrobial Resistance and COVID-19.
https://epha.org/wp-content/uploads/2021/11/covidvsamr-2021-epha.pdf
62 EPHA et al. (2021). Position Paper on the Pharmaceutical Strategy.12 | EPHA | AN OVERVIEW OF AMR
Professional user engagement is important in the decision-making process to ensure awareness and
understanding of the issue, policy relevance and, in turn, implementation success. European level
policy-making process currently allows for input through public consultations; however, this method
tends to favour already aware and politically engaged professionals. Other avenues to develop interest
and opportunities for continuous collaboration in policy development, realising the expertise that
health professionals, veterinarians, agri- and aquacultural farmers can provide, would help strengthen
AMR policy, as well as encourage adherence.
Civil society engagement is invaluable to policy development as it can provide a collective voice for
public, animal and/or environmental health. Moves to engage beyond public consultations sees the
EC chaired EU AMR One Health Network, traditionally consisting of Commission experts, EU agencies,
public and animal health representatives from Members States, planning to expand to include civil
society organisations. Similar permanent developments at the global level could also prove beneficial
to policy development. 63
Conclusions
Multiple areas still require attention in order to overcome the AMR public health crisis, including
ensuring global surveillance coverage in all aspects of One Health; addressing every driver sufficiently,
with attention given to the compounding effect of other global public health issues; supporting the
research and development of both short- and long-term medical interventions; and developing further
avenues for professional and civil society policy involvement.
63 AMR Stakeholder Network. (2019). Roadmap.EUROPEAN PUBLIC HEALTH ALLIANCE (EPHA) Rue de Trèves 49-51 • 1040 Brussels (BELGIUM) • +32 (0) 2 230 30 56 • https://epha.org/ • epha@epha.org
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